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CT - Anatomy and Pathology of Uterus and Ovaries

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1 CT - Anatomy and Pathology of Uterus and Ovaries
Migdalia Ordonez OHSU Summer 2012

2 Purpose of this Presentation
Review Pelvic anatomy on CT. Review common Pelvic pathologies on CT.

3 Topics to review: (use hyperlinks to jump to different sections)
CT basics Normal Anatomy Non-neoplasm Neoplasms

4 CT basics Normal Anatomy Non-neoplasm Neoplasm First, some basic CT Principles you will need for this learning module.

5 View the image is as if you were looking up from the patient’s feet.
CT basics Normal Anatomy Non-neoplasm Neoplasm CT Basics Right Left View the image is as if you were looking up from the patient’s feet.

6 CT Basics > > > >
Normal Anatomy Non-neoplasm Neoplasm CT Basics > > > > Metal Bone Water Fat Air (tissue and blood) +500 to HU to -500 HU HU to -50 HU to HU Things appear whiter according to their relative densities. This property is called “Attenuation” and it is quantified in Hounsfield Units (HU), which can be measured on CT viewing software.

7 Quick review Is it metal, bone, water, fat, or air A. _______
CT basics Normal Anatomy Non-neoplasm Neoplasm Quick review Is it metal, bone, water, fat, or air A. _______ B. _______ C. _______ D. _______ C. D. B. A.

8 Answers Is it metal, bone, water, fat, or air A. Muscle B. Bone C. Air
CT basics Normal Anatomy Non-neoplasm Neoplasm Answers Is it metal, bone, water, fat, or air A. Muscle B. Bone C. Air D. Fat C. D. B. A.

9 Normal Pelvic Anatomy Uterus Ovary CT basics Normal Anatomy
Non-neoplasm Neoplasm Normal Pelvic Anatomy Uterus Ovary

10 Identify structures in next slide:
CT basics Normal Anatomy Non-neoplasm Neoplasm Identify structures in next slide:

11 CT basics Normal Anatomy Non-neoplasm Neoplasm Identify structures Landmarks: Ovaries usually lateral to uterus and inferior to bifurcation of Iliac vessels C A B C D E F G

12 Identify structures A B C D E F G Bladder Piriformis muscle
CT basics Normal Anatomy Non-neoplasm Neoplasm Identify structures A B C D E F G Bladder Piriformis muscle Right ovary Rectum Left ureter Psoas muscle Uterine body

13 CT basics Normal Anatomy Non-neoplasm Neoplasm Another look:

14 Side note: This is a… Hysterosalpingogram
CT basics Normal Anatomy Non-neoplasm Neoplasm Side note: This is a… Hysterosalpingogram Radio-opaque material is injected into the cervical canal. Procedure is used to investigate the shape of uterine cavity and shape and patency of fallopian tubes. Included here to review anatomy

15 CT basics Normal Anatomy Non-neoplasm Neoplasm Pathology

16 Pathology – Non-neoplasm
CT basics Normal Anatomy Non-neoplasm Neoplasm Pathology – Non-neoplasm Describe what you see: Attenuation (density) Heterogeneous v. Homogenous Well-circumscribed v. Indistinct Borders Enhancing (lights up with contrast) v. non-enhancing Location

17 CT basics Normal Anatomy Non-neoplasm Neoplasm Case #1 28 year old female presents with fever, lower abdominal pain, new vaginal discharge and complaints of painful intercourse. Physical exam: Febrile and cervical motion tenderness. A computed tomography (CT) was done, see next slide.

18 CT basics Normal Anatomy Non-neoplasm Neoplasm Describe what you see:

19 Pelvic Inflammatory Disease
CT basics Normal Anatomy Non-neoplasm Neoplasm Enlarged uterus of soft-tissue attenuation, flanked at the posterior aspects by tortuous, thick-walled oviduct Left greater than Right filled with material of fluid-attenuation. Pelvic Inflammatory Disease

20 CT basics Normal Anatomy Non-neoplasm Neoplasm Case #2 36 year old female presents with sudden onset bilateral pelvic pain, left side worse than right. History of pelvic inflammatory disease a year ago treated with antibiotics. Physical exam: Tender to palpation in bilateral lower abdomen, L greater than R. Entire pelvis tender to palpation. A computed tomography (CT) was done, see next slide.

21 CT basics Normal Anatomy Non-neoplasm Neoplasm Describe what you see:

22 Coronal view - Describe what you see:
CT basics Normal Anatomy Non-neoplasm Neoplasm Coronal view - Describe what you see:

23 CT basics Normal Anatomy Non-neoplasm Neoplasm Left pelvis there is a cystic lesion with heterogeneous enhancement. The lesion appears to be contiguous with the uterus, likely representing… Tubo-ovarian abscess

24 CT basics Normal Anatomy Non-neoplasm Neoplasm Tubo-ovarian abscess

25 CT basics Normal Anatomy Non-neoplasm Neoplasm Case #3 23 year old female presents with fever, chills, lower abdominal pain, recent history of PID treated with antibiotics. Physical exam: Febrile and cervical motion tenderness. A computed tomography (CT) was done, see next slide.

26 CT basics Normal Anatomy Non-neoplasm Neoplasm Describe what you see:

27 CT basics Normal Anatomy Non-neoplasm Neoplasm Uterus has large, heterogeneous mass with areas of soft-tissue attenuation and areas of fluid attenuation Tubo-ovarian abscess

28 CT basics Normal Anatomy Non-neoplasm Neoplasm Case #4 23 year old female presents to ED by ambulance due to motor vehicle accident. She is complaining of lower abdominal / pelvic pain. Physical exam: Pelvis tender to palpation. A computed tomography (CT) was done, see next slide.

29 CT basics Normal Anatomy Non-neoplasm Neoplasm Describe what you see:

30 IUD Highly attenuated object in uterus, otherwise normal pelvic CT
CT basics Normal Anatomy Non-neoplasm Neoplasm Highly attenuated object in uterus, otherwise normal pelvic CT IUD

31 CT basics Normal Anatomy Non-neoplasm Neoplasm Case #5 21 year old female with 2 days of progressively worsening pelvic pain. She missed last period. She has been feeling nauseated for past 3 weeks. Physical exam: right pelvic tenderness, breast tenderness. A computed tomography (CT) was done, see next slide.

32 CT basics Normal Anatomy Non-neoplasm Neoplasm Describe what you see:

33 Contrast enhanced axial CT image shows strong enhancing ring-like mass (arrow) that represents gestational sac without hemoperitoneum CT basics Normal Anatomy Non-neoplasm Neoplasm Ectopic pregnancy

34 Pathology - Neoplasm Describe what you see: Attenuation (density)
CT basics Normal Anatomy Non-neoplasm Neoplasm Pathology - Neoplasm Describe what you see: Attenuation (density) Heterogeneous v. Homogenous Well-circumscribed v. Indistinct Borders Enlarged v. atrophied Enhancing (lights up with contrast) v. non-enhancing Location

35 CT basics Normal Anatomy Non-neoplasm Neoplasm Case #6 13 year old female presents with abdominal discomfort and feeling bloated. Stomach seems to be growing wider. Physical exam: Increased abdominal girth A computed tomography (CT) was done, see next slide.

36 CT basics Normal Anatomy Non-neoplasm Neoplasm Describe what you see:

37 (Mature dermatoid cyst)
CT basics Normal Anatomy Non-neoplasm Neoplasm Mid pelvis there is large, thin-walled, cystic structure of fluid-attenuation. At the periphery of this structure are a few distinct regions of heterogeneous tissue. Within the right lateral aspect lies a foci of bone-density material. Within the left lateral aspect lies a heterogeneous foci of fat and soft-tissue densities Teratoma (Mature dermatoid cyst)

38 CT basics Normal Anatomy Non-neoplasm Neoplasm Case #7 48 year old female was involved in motor vehicle accident. She is shaken up from accident but otherwise feeling fine. Physical exam: Pt is in no acute distress. No signs or symptoms of pain. Patient insisted having a CT to rule out bleeds. A computed tomography (CT) was done, see next slide.

39 Describe what you see: Clue: this arises from the ovary CT basics
Normal Anatomy Non-neoplasm Neoplasm Describe what you see: Clue: this arises from the ovary

40 Serous Cystadenoma (benign)
CT basics Normal Anatomy Non-neoplasm Neoplasm Posterior aspect of the pelvis lies a well-circumscribed, thin-walled, non-septated cystic structure containing fluid-density material Clue: this arises from the ovary Serous Cystadenoma (benign) Incidental finding on CT

41 CT basics Normal Anatomy Non-neoplasm Neoplasm Case #8 58 year old female presents to clinic with bloating, back pain, urinary urgency, constipation, and tiredness for 6 months. Recently she developed pelvic pain, vaginal bleeding, and unintentional weight loss. Physical exam: Abdomen tender to palpation throughout. Pelvic tenderness. A computed tomography (CT) was done, see next slide.

42 Describe what you see: Clue: This arises from the ovary CT basics
Normal Anatomy Non-neoplasm Neoplasm Describe what you see: Clue: This arises from the ovary

43 Cystadenocarcinoma (Malignant)
CT basics Normal Anatomy Non-neoplasm Neoplasm The pelvic cavity is grossly distended by multiple well-circumscribed, thin-walled, septated, lobular structures of fluid-density. These structures are compressing but don’t seem to invade surrounding pelvic tissues Cystadenocarcinoma (Malignant) Note: Septations and lobulated surface

44 Sources As well as IMPAX, EPIC, and WIKIPEDIA CT basics Normal Anatomy
Non-neoplasm Neoplasm Sources Siddall KA. Multidetector CT of the female pelvis. Radiol Clin North Am. 01-NOV-2005; 43(6): Casillas J, Joseph RC, Guerra JJ Jr. CT appearance of uterine leiomyomas. Radiographics Nov;10(6): Foshager MC, Walsh JW. CT anatomy of the female pelvis: a second look. Radiographics Jan;14(1):51-64; Outwater EK, Siegelman ES, Hunt JL. Ovarian teratomas: tumor types and imaging characteristics. Radiographics Mar-Apr;21(2): Pannu, HK, et al. MD CT Evaluation of Cervical Cancer: Spectrum of Disease. Radiographics 2001; 21:1155–1168 Rha SE, et al. CT and MR imaging features of adnexal torsion. Radiographics Mar-Apr;22(2): Roberts JL, Dalen K, Bosanko CM, Jafir SZ. CT in abdominal and pelvic trauma. Radiographics Jul;13(4): Roobolamini, SA. Imaging of Pregnancy-related Complications. Radiographics 1993; 13: Saksouk FA, Johnson SC. Recognition of the ovaries and ovarian origin of pelvic masses with CT. Radiographics Oct;24 Suppl 1:S Sam JW, Jacobs JE, Birnbaum BA. Spectrum of CT findings in acute pyogenic pelvic inflammatory disease. Radiographics Nov-Dec;22(6): Yang DM. Retroperitoneal cystic masses: CT, clinical, and pathologic findings and literature review. Radiographics Sep-Oct;24(5): Buy, J-N, et al. Cystic Teratoma of the Ovary: CT Detection. Radiology 1989; 171: As well as IMPAX, EPIC, and WIKIPEDIA


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